|Study title: Behavioural therapy approaches for the management of low back pain: An up-to-date systematic review
Authors: Vitoula K, Venneri A, Varrassi G et al.
Publication Information: Pain and Therapy 2018; 7(1): 1-12. doi: 10.1007/s40122-018-0099-4.
Low back pain (LBP) is one of the most common reasons for seeking medical treatment. It is often categorized by its temporal evolution, which is generally defined as follows: acute (lasting less than four weeks), subacute (lasting between four and 12 weeks) and chronic (lasting greater than 12 weeks) (1, 2). This temporal classification is important, as chronic pain may relate to prolonged, impaired quality of life due to psychological symptoms, in addition to physical symptoms, requiring adaptive interventions (3).
The objective of this review was to summarize strategies and evaluate the evidence regarding the effectiveness of behavioural approaches in the management of patients with LBP.
Biofeedback is defined as: ‘the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will.’ As a relaxation technique aimed at educating patients to alter autonomic functions that are not normally under voluntary control (such as blood pressure, heart rate etc.), it has been found to be useful in reducing paraspinal muscle tension in patients with chronic LBP (4). Unfortunately, in a study of electromyography (EMG) biofeedback in patients with LBP, a direct analgesic effect was not found (5).
Cognitive Behavioral Therapy:
Cognitive behavioral therapy (CBT) is comprised of four components: 1) the patient’s understanding of pain and pain perception; 2) the use of active coping skills; 3) maintenance of pain-coping strategies; and 4) problem-solving skills that enable patients to deal with pain and challenging situations (6). CBT aims to assist patients in the development of adaptive thought patterns, as it is believed that the patient’s thoughts and beliefs about their symptoms will influence their behaviors (7). In patients with chronic LBP, a link between negative beliefs and increased pain perception has been demonstrated (8).
Graded activity/graded exposure CBT strategies aim to increase an individual’s tolerance of activity (9). Individual sessions show similar effectiveness to physiotherapy (10) and motor control exercises (11), while group sessions have demonstrated significant improvements in pain intensity (12). These strategies have also been demonstrated to be a successful method of restoring occupational function and facilitating return to work in patients with subacute LBP (13).
Individual sessions of CBT have often been studied as a component of a multidisciplinary approach, however the evidence is unclear, as some studies demonstrated a significant improvement in pain intensity when CBT was included (14, 15), while others did not (16-21). As a stand-alone therapy in a patient population of candidates for spinal surgery, those who received CBT demonstrated less fear avoidance at 12 months than the patients who underwent spinal fusion (22), and these findings were confirmed at the four-year follow up (23). It is likely the heterogeneity in patient populations, interventions and co-interventions is responsible for the disparity of these results. It is important to note that neither telephone-based (24) nor videotapes (25) were found to be effective forms of adjunctive therapy.
Group sessions of CBT demonstrated similarly unclear results. In a study comparing multidisciplinary care (including CBT strategies) to traditional exercises, multidisciplinary care was found to be superior in reducing pain and kinesiophobia, de-catastrophizing and enhancing quality of life, and the effects lasted for two years following the intervention (26). Outpatient CBT sessions focused on negative reinforcement of pain behaviors reduced pain intensity for up to 12 months, particularly when combined with aerobic exercise (27).
In a population of patients with the potential for acute, severe pain following surgery, preoperative CBT was found to facilitate mobility and reduce the need for rescue painkillers in the acute post-surgical phase (28). CBT may also be a beneficial intervention for patients with acute LBP, as it may prevent chronicity in these patients (29). CBT may also improve the quality of sleep (30) and decrease pain perception in patients with depression and anxiety (31).
Mindfulness-Based Stress Reduction:
Mindfulness has been described as “non-elaborative, non-judgmental, moment-to-moment awareness” (32). Mindfulness-based stress reduction (MBSR) includes meditation, yoga and body scan (sequential focus on different parts of the body) (32). These therapies are considered feasible, acceptable and safe for patients with LBP (33, 34). In addition to usual care, MBSR may result in improvements in pain and functional limitations in patients with LBP (35, 36). This form of treatment certainly warrants more research.
Acceptance and Commitment Therapy:
Acceptance and commitment therapy teaches patients how to accept unpleasant sensations and thoughts, without attempting to avoid or change them (37). The intention is not to reduce pain, rather to teach patients to accept the pain and let go of ineffective pain control strategies (37). This approach, as with some of the others discussed here, takes some time and requires further research. At the time of publication for this review, a study was underway in a population of patients with CLBP (38).
Clinical Application & Conclusions:
This review outlined behavioral strategies that may assist clinicians in treating patients with LBP. These therapies appear to be most effective in altering pain perception and regaining functionality. While the evidence is unclear, it appears that the addition of CBT to multidisciplinary care is the most effective way to incorporate behavioral strategies within the biopsychosocial model (most clinicians wouldn’t use this sort of thing as the sole intervention, so this makes sense!). Future research regarding specific interventions and outcomes (pain intensity, pain acceptance, reduction of medication use, disability and quality of life) will assist clinicians in personalizing therapeutic approaches based on patient-specific needs.
- A systematic literature search was conducted on PubMed using two Medical Subject Headings: ‘low back pain’ and ‘behavioral therapy’.
- Articles had to meet the following criteria: original research, study human adult subjects, publication in English primarily focused on the effectiveness of behavioral therapy, and involve patients with LBP to be included.
- Critical appraisal, data extraction and data synthesis were unfortunately not disclosed.
- This review provided a helpful summary of various behavioral strategies that may be used in the treatment of patients with LBP.
- As CBT was the most widely researched strategy, findings were divided into method of use (individual session, group sessions, telephone/video) to assist clinicians in determining the most effective manner to utilize CBT with patients.
- The primary limitation of this study is the lack of appropriate methodology. Without discussion of critical appraisal, these results must be interpreted with a great deal of caution, though they do provide an interesting overview of the literature regarding behavioral therapy for LBP.
- Given the varied methodologies of the included studies, specifics regarding interventions cannot be gleaned from this review.
- The paucity of research relating to most behavioral interventions limits the utility of the results and conclusions, but existing work is helpful for informing and stimulating future research.
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Dr. Shawn Thistle is a practising chiropractor, educator, international speaker, knowledge-transfer leader, evidence-based health care advocate, entrepreneur and medicolegal consultant. He founded RRS Education in 2006 and currently acts as the company’s CEO. RRS Education helps chiropractors and other manual medicine clinicians around the world integrate research into patient care via weekly research reviews, online courses and seminars. rrseducation.com